NEW TOOL TO FIGHT HEALTH INSURANCE DISCRIMINATION

Transcription

1 Presented by: NEW TOOL TO FIGHT HEALTH INSURANCE DISCRIMINATION FILING COMPLAINTS TO STATE INSURANCE COMMISSIONERS MAY 18, 2015 Center for Health Law and Policy Innovation

2 Ask questions All attendees are in listenonly mode Everyone can ask questions at any time using the questions feature During Q & A breaks, the moderators will read questions that have been submitted If you are having audio or webinar trouble, go to HIVHealthReform.org/webina rs for troubleshooting help Center for Health Law and Policy Innovation 2

3 Can t hear the audio? Use your telephone! Click on the audio tab Dial the telephone number, access code, and PIN you see on your computer Center for Health Law and Policy Innovation 3

4 Download the slides! Go to to download the slides, which are featured in the home page slider. Webinars & recordings will be archived at Center for Health Law and Policy Innovation 4

5 Follow on social media! We will be Live Tweeting during the webinar. Start the conversation on Twitter. Use #HIV and #ACA. Facebook: HIVHealthReform.org Center for Health Law and Policy Innovation 5

6 Overview This webinar will: Provide information on what consumers, providers and advocates need to know to file complaints to State Departments of Insurance (DOIs) to fight HIV health insurance discrimination Walk us through each step in the process of completing newly available template complaint letters Discuss next steps in the effort to reduce HIV health insurance discrimination! Filing complaints is important because: Complaints to insurance commissioners have been proven to be a powerful tool, often resulting in significant regulatory changes Even if the complaint is initially unsuccessful, it can help support a successful litigation campaign to combat insurance discrimination Center for Health Law and Policy Innovation 6

7 THE IMPORTANCE OF REGULATORY COMPLAINTS WHY THESE LETTERS ARE CRUCIAL TO IMPROVING HEALTH CARE ACCESS Center for Health Law and Policy Innovation 7

8 THERE ARE MANY FORMS OF DISCRIMINATION Among others, discriminatory practices include: Disproportionately high co-pays, co-insurance, and deductibles that make it impossible for someone living with HIV to afford coverage No coverage for anti-retroviral or other expensive drugs An unfair appeals process that doesn t provide a chance to appeal an eligibility or coverage denial The Affordable Care Act (ACA) specifically addresses some discriminatory practices, such as prohibiting: Higher premiums based on health status Denial of coverage for pre-existing conditions Annual/lifetime limits on coverage Other discriminatory practices are not explicitly prohibited, but are still protection under broad ACA anti-discrimination provisions and other laws Center for Health Law and Policy Innovation 8

9 STATE INSURANCE COMMISSIONERS ARE RESPONSIBLE FOR ACA ENFORCEMENT Historically, the insurance industry has been regulated almost exclusively by individual state governments While under ACA the federal government has some oversight responsibilities, state insurance regulators are charged with frontline oversight With the ACA state regulators must now oversee two insurance markets the new ACA Marketplaces (Exchanges) & the traditional health insurance market The ACA establishes some regulations that apply only to the Marketplace plans (such as actuarial value standards, network adequacy, uniform summaries of coverage and Essential Health Benefits) Some states are actively engaged in their ACA responsibilities, enforcing some of the new transparency and coverage requirements However, most states have not overhauled their insurance regulations in response to the ACA DOI complaints will put pressure on states to update their regulations to meet Marketplace oversight responsibilities as required under the law Center for Health Law and Policy Innovation 9

10 INSURANCE COMMISSIONERS NEED TO HEAR COMPLAINTS State DOIs must face consumer pressure in order to effectively regulate their insurance markets Yet, few insurance regulators have received complaints from the HIV community documenting discriminatory practices The lack of complaints allows them to ignore the discriminatory actions of their local health insurers Appropriate topics for complaints to state regulators in private health insurance plans include: Changing coverage after the open enrollment period ends Refusing to cover the care and treatment people living with HIV need Requiring unreasonably high cost-sharing for HIV treatment We must ensure that our insurance commissioners in every state hear from us and feel the pressure to stop this discrimination! Center for Health Law and Policy Innovation 10

11 DEPARTMENT OF INSURANCE TEMPLATE COMPLAINTS WHEN, WHY AND HOW TO USE THESE TEMPLATES Center for Health Law and Policy Innovation 11

12 TARGET AUDIENCE FOR THE DOI TEMPLATE The DOI Template is intended to support the development of grievance letters from advocates/providers to state s DOI regulators Can also be used by consumers although a simplified version of the letter intended for consumer use will be discussed later The DOI Template can also be modified to send to insurers We have seen success in states such as Louisiana when this letter was modified to send to insurers Can also consider cc ing relevant insurers on the letter to regulators to give them notice For help modifying please contact CHLPI Center for Health Law and Policy Innovation 12

13 WHEN TO USE THE DOI TEMPLATE The DOI Template can be used in lieu of, or to compliment, a litigation strategy The purpose of the DOI Template is to draw regulators attention to consumers issues A regulatory complaint may avoid creating an unnecessarily adversarial relationship with your state s insurers, the way litigation might Regulators may respond more quickly to a complaint than it would take to resolve the issue in court OR Even sympathetic regulators may require the pressure of litigation (in addition to the complaint letters) in order to respond effectively We have seen this scenario play out frequently with the U.S. Department of Health and Human Services, who both need political cover and are motivated by impending litigation Center for Health Law and Policy Innovation 13

14 WHY USE THE DOI TEMPLATE The DOI Template can be used to address a variety of complaints: Insurers aren t covering important HIV medications Insurers are changing coverage after the end of open enrollment Insurers are practicing adverse tiering (i.e., placing HIV medications in formulary tiers with high cost sharing) Insurers are requiring onerous prior authorization or other kinds of medical management requirements for HIV medications Insurers are requiring use of mail-order pharmacies for HIV medication (note: federal regulations going into effect in 2016 will help alleviate this issue) The most effective letters are those that are specific and detailed! Give medication names, denial of coverage dates, and attach documentation Center for Health Law and Policy Innovation 14

15 HOW TO USE THE DOI TEMPLATE The first page will require the most modifications All fields requiring your input are highlighted Can use the letter to highlight multiple complaints Remember to delete the inapplicable material! Center for Health Law and Policy Innovation 15

16 HOW TO USE THE DOI TEMPLATE The next section strongly states the protections guaranteed in the ACA Regulators must be reminded that insurers are prohibited from discriminating against consumers on the basis of disability! This section is specific to health plans offered on the Marketplaces If your complaint relates to an employer plan or a Medicare Part D plan contact CHLPI for help modifying the DOI Template New federal regulations on this subject may be forthcoming CHLPI will update the DOI Template as necessary Center for Health Law and Policy Innovation 16

17 CURRENT STANDARDS OF HIV CARE Most regulators will not be familiar with current HIV standards This section provides an overview of HHS guidelines, giving regulators a clear benchmark for evaluating the health care access offered by insurers Center for Health Law and Policy Innovation 17

18 ANTI-DISCRIMINATION MANDATES This section discusses federal anti-discrimination regulatory language and explains that state DOIs are responsible for enforcing these regulations Again, these regulations may be subject to change Center for Health Law and Policy Innovation 18

19 CONSUMER AND OTHER DOI TEMPLATES The Consumer DOI Template is intended for use by consumers who may not feel as comfortable with some of the scientific and legal language of the DOI template The Consumer DOI Template: Is shorter (three v. seven pages) Has minimal citations Has an extremely abbreviated standard of care section Has a shortened anti-discrimination mandates section Consumers are welcome to use the longer DOI Template, if they feel comfortable with it CHLPI is working on several other, related, DOI Templates, including: A hepatitis C specific template A generic, non-disease specific, template Template appeals letters for providers to use with insurers Center for Health Law and Policy Innovation 19

20 CONCLUSION NEXT STEPS, FINAL TIPS, AND QUESTIONS Center for Health Law and Policy Innovation 20

21 FINAL TIPS FOR USING THE DOI TEMPLATES Always download a fresh copy of the DOI Template (consumer or provider) from chlpi.org, hivhealthreform.org or HIVMA s website These templates may be subject to changes, especially if new federal regulations are issued Consider contacting CHLPI when using the DOI Template We may be able to better tailor the Template for your needs We may be able to give you insight into what other providers, advocates, and consumers in your state have done Let CHLPI know you are using the DOI Template, even if you don t wish to consult with us It will be helpful to know who is using the DOI Template and what sort of pressure regulators are facing in each state Please share this resource widely The more letters, the more powerful the impact! Center for Health Law and Policy Innovation 21

22 NEXT STEPS AFTER USING THE DOI TEMPLATES Consider sending your complaint electronically and in hardcopy A hardcopy can be a good follow up to a PDF ed letter electronically sent to the appropriate regulators Follow up within a few weeks and offer to meet with regulators to discuss Let insurers know you are sending information to regulators so that they will feel pressure Can cc insurers on these letters or send separate letters Offer to meet with insurers Consider a litigation strategy in tandem with regulatory complaints and appeals You do not have to choose one over the other Litigation can be slower and costlier than regulatory complaints Center for Health Law and Policy Innovation 22

23 Questions Ask your questions using the webinar chat feature. If we don t get to your question it will be logged and we ll do our best to follow up! Center for Health Law and Policy Innovation 23

24 Speak Up! With support from the M A C AIDS Fund, a team of national and state partners has established SPEAK UP to monitor, assess and document ACA implementation success and barriers to HIV care Through SPEAK UP we see patterns of discrimination emerging that need to be addressed, educate state and federal officials about what s happening on the ground, advocate for change, and report back to the community Monitoring and documentation is critical to help inform and shape state and federal policy to ensure the needs of people living with HIV are addressed as the ACA is implemented To SPEAK UP!, visit: Center for Health Law and Policy Innovation 24

25 Carmel Shachar, Staff Attorney Boylston Street Jamaica Plain, MA Connect with us online HarvardCHLPI HarvardCHLPI